Language：English   Publishing type：Research paper (scientific journal)  

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

DOI： 10.1186/s40560-021-00555-7

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Language：English   Publishing type：Research paper (international conference proceedings)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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PURPOSE: Compared with open thoracotomy, minimally invasive esophagectomy (MIE) methods, such as transhiatal or thoracoscopic esophagectomy, likely have lower morbidity. However, the relationship between intraoperative fluid management and postoperative complications after MIE remains unclear. Thus, we investigated the association of cumulative intraoperative fluid balance and postoperative complications in patients undergoing MIE. METHODS: This single-center retrospective cohort study examined patients undergoing thoracoscopic esophagectomy for esophageal cancer in the prone position. Postoperative complications included pneumonia, arrhythmia, thrombotic events and acute kidney injury (AKI). We compared patients with higher and lower intraoperative fluid balance (higher and lower than the median). Multivariable logistic regression analyses were performed to estimate the odds ratio of intraoperative fluid balance status on the incidence of postoperative complications. RESULTS: In total, 135 patients were included in the study. Postoperative complications occurred in 43 (32%), including cardiac arrhythmia (n = 12, 9%), thrombosis (n = 20, 15%), pneumonia (n = 13, 10%), and AKI required hemodialysis (n = 1, 1%). Patients with a higher fluid balance had higher incidence of complications than those with a lower fluid balance (46% vs. 18%, p < 0.001). After adjusting for age, ASA-PS ≥ III, blood loss, and the use of radical surgery, the higher intraoperative fluid balance group was significantly and independently associated with postoperative complications (adjusted OR 5.31, 95% CI 2.26-13.6, p < 0.0001). CONCLUSIONS: In patients undergoing thoracoscopic esophagectomy in the prone position, a greater intraoperative positive fluid balance was independently associated with a higher incidence of complications.

DOI： 10.1007/s00540-020-02766-y

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Language：English   Publishing type：Research paper (scientific journal)  

Tachycardia is common in intensive care units (ICUs). It is unknown whether tachycardia or prolonged tachycardia affects patient outcomes. We investigated the association between tachycardia and mortality in critically ill patients. This retrospective cohort study's primary outcome was patient mortality in the ICU and the hospital. We stratified the patients (n=476) by heart rate (HR) as LowHR, MediumHR, and HighHR groups. We also stratified them by their durations of HR >100 (prolonged HR; tachycardia): MildT, ModerateT, and SevereT groups. We determined the six groups' mortality. The ICU mortality rates of the LowHR, MediumHR, and HighHR groups were 1.0%, 1.5%, and 7.9%, respectively; significantly higher in the HighHR vs. LowHR group. The in-hospital mortality rates of these groups were 1%, 4.5%, and 14.6%, respectively; significantly higher in the HighHR vs. LowHR group. The ICU mortality rates of the MildT, ModerateT, and SevereT groups were 0.9%, 5.6%, and 57.1%, respectively. The mortality of the HRT=0 (i.e., all HR ≤ 100) patients was 0%. The in-hospital mortality rates of the MildT, ModerateT, and SevereT groups were 1.8%, 16.7%, and 85.7%, respectively; that of the HRT=0 patients was 0.5%. Both higher HR and prolonged tachycardia were associated with poor outcomes.

DOI： 10.18926/AMO/56650

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Language：English   Publishing type：Research paper (scientific journal)  

Avoiding hypoxaemia is considered crucial in cardiac surgery patients admitted to the intensive care unit (ICU). However, avoiding hyperoxaemia may also be important. A conservative approach to oxygen therapy may reduce exposure to hyperoxaemia without increasing the risk of hypoxaemia. Using a before-and-after design, we evaluated the introduction of conservative oxygen therapy (target SpO2 88%-92% using the lowest FiO2) for cardiac surgical patients admitted to the ICU. We studied 9041 arterial blood gas (ABG) datasets: 4298 ABGs from 245 'conventional' and 4743 ABGs from 298 'conservative' oxygen therapy patients. During mechanical ventilation (MV) and while in the ICU, compared to the conventional group, conservative group patients had significantly lower FiO2 exposure and PaO2 values ( P < 0.001 for each). Accordingly, using the mean PaO2 during MV, more conservative group patients were classified as normoxaemic (226 versus 62 patients, P < 0.01), fewer as hyperoxaemic (66 versus 178 patients, P < 0.01) and no patient in either group as hypoxaemic or severely hypoxaemic. Moreover, more ABG samples were hyperoxaemic or severely hyperoxaemic during conventional treatment ( P < 0.001). Finally, there was no difference in ICU or hospital length of stay, ICU or hospital mortality or 30-day mortality between the groups. Our findings support the feasibility and physiological safety of conservative oxygen therapy in patients admitted to ICU after cardiac surgery.

DOI： 10.1177/0310057X19838753

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Glucose transporter type 1 deficiency syndrome (GLUT1DS) causes central nervous system dysfunction including intractable epilepsy caused by impaired glucose transport to the brain. To prevent convulsions and maintain an energy source for the brain in patients with GLUT1DS, the maintenance of adequate ketone body concentrations, compensation of metabolic acidosis, and reduction of surgical stress are essential. We here report the perioperative management of a child with GLUT1DS.

DOI： 10.1213/XAA.0000000000000727

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BioMed Central Ltd.  

Background: The interest in perioperative lung protective ventilation has been increasing. However, optimal management during one-lung ventilation (OLV) remains undetermined, which not only includes tidal volume (VT) and positive end-expiratory pressure (PEEP) but also inspired oxygen fraction (FIO2). We aimed to investigate current practice of intraoperative ventilation during OLV, and analyze whether the intraoperative ventilator settings are associated with postoperative pulmonary complications (PPCs) after thoracic surgery. Methods: We performed a prospective observational two-center study in Japan. Patients scheduled for thoracic surgery with OLV from April to October 2014 were eligible. We recorded ventilator settings (FIO2, VT, driving pressure (ΔP), and PEEP) and calculated the time-weighted average (TWA) of ventilator settings for the first 2 h of OLV. PPCs occurring within 7 days of thoracotomy were investigated. Associations between ventilator settings and the incidence of PPCs were examined by multivariate logistic regression. Results: We analyzed perioperative information, including preoperative characteristics, ventilator settings, and details of surgery and anesthesia in 197 patients. Pressure control ventilation was utilized in most cases (92%). As an initial setting for OLV, an FIO2 of 1.0 was selected for more than 60% of all patients. Throughout OLV, the median TWA FIO2 of 0.8 (0.65-0.94), VT of 6.1 (5.3-7.0) ml/kg, ΔP of 17 (15-20) cm H2O, and PEEP of 4 (4-5) cm H2O was applied. Incidence rate of PPCs was 25.9%, and FIO2 was independently associated with the occurrence of PPCs in multivariate logistic regression. The adjusted odds ratio per FIO2 increase of 0.1 was 1.30 (95% confidence interval: 1.04-1.65, P =0.0195). Conclusions: High FIO2 was applied to the majority of patients during OLV, whereas low VT and slight degree of PEEP were commonly used in our survey. Our findings suggested that a higher FIO2 during OLV could be associated with increased incidence of PPCs.

DOI： 10.1186/s12871-018-0476-x

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Publishing type：Research paper (scientific journal)   Publisher：Open Access Text Pvt, Ltd.  

DOI： 10.15761/pccm.1000148

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Language：Japanese   Publisher：The Japanese Society of Intensive Care Medicine  

A 35-year-old pregnant woman was referred to our hospital with suspected acute pancreatitis at 39 weeks of gestation. On admission, serum triglyceride (TG) level was 11,936 mg/dl and abdominal dynamic CT revealed severe acute pancreatitis. In order to avoid further progression of hypertriglyceridemia and acute pancreatitis, a cesarean section was performed. We then performed low density lipoprotein (LDL) apheresis for the hypertriglyceridemia with consideration of safety. After three cycles of LDL apheresis, serum TG level declined to 1,764 mg/dl. On the 15th day of hospitalization, she was discharged from our hospital without any complications. Treatment of hypertriglyceridemia, including plasma apheresis and heparin-insulin therapy, is important in addition to treatment of acute pancreatitis to reduce the risk of exacerbation of acute pancreatitis in hypertriglyceridemia-induced acute pancreatitis (HIAP). LDL apheresis would be safer than plasma exchange in terms of electrolyte disturbance and transfusion-related complication. LDL apheresis might be effective for patients with HIAP.

DOI： 10.3918/jsicm.24_26

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：OKAYAMA UNIV MED SCHOOL  

A 32-year-old woman, pregnant with twins, presented with a chief complaint of general fatigue. Her general condition had rapidly deteriorated since her last visit to the primary obstetrician; the patient was then referred to our hospital because of suspected fetal death. She underwent emergency cesarean section because fetal death had indeed occurred, and she was then admitted to the intensive care unit (ICU). On ICI: admission, she was found to he in shock. Laboratory analysis revealed extreme hemoconcentration and a low albumin level, and initially, septic shock with obstetric complications was suspected. However, because she did not respond to conventional therapy but instead, rapidly developed severe generalized edema, systemic capillary leak syndrome (SCLS) was diagnosed. The patient remained in shock for several days until undergoing plasma exchange (PE), despite some earlier empirical treatments. She eventually recovered from profound shock status and was discharged from the ICU without sequelae. Among potentially effective treatments, PE seemed to be the most reasonable choice for the treatment of her SCLS.

DOI： 10.18926/AMO/54814

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER IRELAND LTD  

Background: In intensive care observational studies, hypercapnia after cardiac arrest (CA) is independently associated with improved neurological outcome. However, the safety and feasibility of delivering targeted therapeutic mild hypercapnia (TTMH) for such patients is untested.
Methods: In a phase II safety and feasibility multi-centre, randomised controlled trial, we allocated ICU patients after CA to 24 h of targeted normocapnia (TN) (PaCO2 35-45 mmHg) or TTMH (PaCO2 50-55 mmHg). The primary outcome was serum neuron specific enolase (NSE) and S100b protein concentrations over the first 72 h assessed in the first 50 patients surviving to day three. Secondary end-points included global measure of function assessment at six months and mortality for all patients.
Results: We enrolled 86 patients. Their median age was 61 years (58, 64 years) and 66 (79%) were male. Of these, 50 patients (58%) survived to day three for full biomarker assessment. NSE concentrations increased in the TTMH group (p = 0.02) and TN group (p = 0.005) over time, with the increase being significantly more pronounced in the TN group (p(interaction)=0.04). S100b concentrations decreased over time in the TTMH group (p &lt; 0.001) but not in the TN group (p = 0.68). However, the S100b change over time did not differ between the groups (p(interaction)=0.23). At six months, 23 (59%) TTMH patients had good functional recovery compared with 18 (46%) TN patients. Hospital mortality occurred in 11 (26%) TTMH patients and 15 (37%) TN patients (p = 0.31).
Conclusions: In CA patients admitted to the ICU, TTMH was feasible, appeared safe and attenuated the release of NSE compared with TN. These findings justify further investigation of this novel treatment. (C) 2016 Published by Elsevier Ireland Ltd.

DOI： 10.1016/j.resuscitation.2016.03.023

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

症例は29歳、男性。5年前に肺動脈性肺高血圧症(pulmonary arterial hypertension、PAH)を指摘されたが、内科的治療は行われていなかった。今回、胸痛を主訴に近医を受診し、造影CTにて肺動脈解離(pulmonary artery dissection、PAD)を指摘されたため、当院へ転院となった。当院入院後、緊急で主肺動脈人工血管置換術および左右肺動脈縫縮術が施行された。術後、PAHに対して早期に治療を開始した。未治療であったためPAHのコントロールに難渋したが、PAH治療薬の多剤併用および厳重な鎮静・挿管・人工呼吸管理を行うことで、POD21に抜管、POD29にICUを退室、POD101に退院となった。PADは非常に致死率の高い疾患であるが、早期の手術および厳重な術後管理により救命できた。(著者抄録)

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Other Link： https://search-tp.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2016&ichushi_jid=J02874&link_issn=&doc_id=20160610390006&doc_link_id=10.3918%2Fjsicm.23.318&url=https%3A%2F%2Fdoi.org%2F10.3918%2Fjsicm.23.318&type=J-STAGE&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00007_3.gif

Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER IRELAND LTD  

Background: In mechanically ventilated (MV) cardiac arrest (CA) survivors admitted to the intensive care unit (ICU) avoidance of hypoxia is considered crucial. However, avoidance of hyperoxia may also be important. A conservative approach to oxygen therapy may reduce exposure to both.
Methods: We evaluated the introduction of conservative oxygen therapy (target SpO(2) 88-92% using the lowest FiO(2)) during MV for resuscitated CA patients admitted to the ICU.
Results: We studied 912 arterial blood gas (ABG) datasets: 448 ABGs from 50 'conventional' and 464 ABGs from 50 'conservative' oxygen therapy patients. Compared to the conventional group, conservative group patients had significantly lower PaO2 values and FiO(2) exposure (p &lt; 0.001, respectively); more received MV in a spontaneous ventilation mode (18% vs 2%; p = 0.001) and more were exposed to a FiO(2) of 0.21 (19 vs 0 patients, p = 0.001). Additionally, according to mean PaO2, more conservative group patients were classified as normoxaemic (36 vs 16 patients, p &lt; 0.01) and fewer as hyperoxaemic (14 vs 33 patients, p &lt; 0.01). Finally, ICU length of stay was significantly shorter for conservative group patients (p = 0.04). There was no difference in the proportion of survivors discharged from hospital with good neurological outcome (14/23 vs 12/22 patients, p = 0.67).
Conclusions: Our findings provide preliminary support for the feasibility and physiological safety of conservative oxygen therapy in patients admitted to ICU for MV support after cardiac arrest (Trial registration, NCT01684124). (C) 2015 Elsevier Ireland Ltd. All rights reserved.

DOI： 10.1016/j.resuscitation.2015.11.026

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：English   Publisher：Ovid Technologies (Wolters Kluwer Health)  

DOI： 10.1097/01.ccm.0000510249.56905.db

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：W B SAUNDERS CO-ELSEVIER INC  

Purpose: The purpose of the study is to assess the effect of a conservative oxygen therapy (COT) (target SpO(2) of 90%-92%) on radiological atelectasis and mechanical ventilation modes.
Materials and methods: We conducted a secondary analysis of 105 intensive care unit patients from a pilot before-and-after study. The primary outcomes of this study were changes in atelectasis score (AS) of 555 chest radiographs assessed by radiologists blinded to treatment allocation and time to weaning from mandatory ventilation and first spontaneous ventilation trial (SVT).
Results: There was a significant difference in overall AS between groups, and COT was associated with lower time-weighted average AS. In addition, in COT patients, change from mandatory to spontaneous ventilation or time to first SVT was shortened. After adjustment for baseline characteristics and interactions between oxygen therapy, radiological atelectasis, and mechanical ventilation management, patients in the COT group had significantly lower "best" AS (adjusted odds ratio, 0.28 [95% confidence interval {CI}, 0.12-0.66]; P = .003) and greater improvement in AS in the first 7 days (adjusted odds ratio, 0.42 [95% CI, 0.17-0.99]; P = .049). Moreover, COT was associated with significantly earlier successful weaning from a mandatory ventilation mode (adjusted hazard ratio, 2.96 [95% CI, 1.73-5.04]; P &lt; .001) and with shorter time to first SVT (adjusted hazard ratio, 1.77 [95% CI, 1.13-2.78]; P = .013).
Conclusions: In mechanically ventilated intensive care unit patients, COT might be associated with decreased radiological evidence of atelectasis, earlier weaning from mandatory ventilation modes, and earlier first trial of spontaneous ventilation. (C) 2015 Elsevier Inc. All rights reserved.

DOI： 10.1016/j.jcrc.2015.07.033

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：W B SAUNDERS CO-ELSEVIER INC  

Objectives: To determine the ability of urinary neutrophil gelatinase-associated lipocalin (uNGAL) to predict cardiac surgery-associated acute kidney injury (CSA-AKI), continuous renal replacement therapy (CRRT), mortality, and a composite outcome of major adverse kidney events at 365 days (MAKE(365)), and to investigate the influence of cardiopulmonary bypass (CPB) on NGAL release.
Design: A prospective observational study.
Setting: A single-center university hospital.
Participants: A cohort of 288. adult cardiac surgery patients.
Interventions: uNGAL was measured at baseline, immediately after surgery, and on days 1 and 2 postoperatively. The authors used the recent Kidney Disease Improving Global Outcomes consensus criteria to define CSA-AKI.
Measurements and Main Results: CSA-AKI occurred in 36.1% of patients. uNGAL rapidly became significantly higher in patients who developed AKI, with peak value immediately after surgery (349.9 [76.6-1446.6] v 90.1 [20.8-328] ng/mg creatinine; p &lt; 0.001). No measure of uNGAL (peak, postsurgery, day 1 or 2 postsurgery) accurately predicted CSA-AKI, CRRT, mortality, or MAKE365. However, immediately after surgery, CPB induced greater uNGAL release compared with off-pump surgery (265.5 mu mol/L [71-989.6] v 48.7 ng/mg creatinine [17-129.8]; p &lt; 0.001). Moreover, such early uNGAL release correlated with CPB duration (r = 0.505; p &lt; 0.001) but not with peak serum creatinine values on day 3 or 7 after surgery.
Conclusions: uNGAL had a limited predictive ability for CSA-AKI or other relevant clinical outcomes after cardiac surgery and appeared to be more closely related to the use and duration of CPB. Thus, its levels may represent the aggregate effect of an inflammatory response to CPB as well as a renal response to cardiac surgery and inflammation. (C) 2015 Elsevier Inc. All rights reserved.

DOI： 10.1053/j.jvca.2015.05.060

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BioMed Central Ltd.  

Introduction: In this study, we aimed to examine the association between paracetamol administration in the intensive care unit (ICU) and mortality in critically ill patients. Methods: We conducted a multicenter retrospective observational study in four ICUs. We obtained information on paracetamol use, body temperature, demographic, clinical and outcome data from each hospital's clinical information system and admissions and discharges database. We performed statistical analysis to assess the association between paracetamol administration and hospital mortality. Results: We studied 15,818 patients with 691,348 temperature measurements at 4 ICUs. Of these patients, 10,046 (64%) received at least 1g of paracetamol. Patients who received paracetamol had lower in-hospital mortality (10% vs. 20%, P &lt
0.001), and survivors were more likely to have received paracetamol (66% vs. 46%
P &lt
0.001). However, patients treated with paracetamol were also more likely to be admitted to the ICU after surgery (70% vs. 51%
P &lt
0.001) and/or after elective surgery (55% vs. 37%
P &lt
0.001). In multivariate logistic regression analysis including a propensity score for paracetamol treatment, we found a significant and independent association between the use of paracetamol and reduced in-hospital mortality (adjusted odds ratio =0.60 (95% confidence interval (CI), 0.53 to 0.68), P &lt
0.001). Cox proportional hazards analysis showed that patients who received paracetamol also had a significantly longer time to death (adjusted hazard ratio =0.51 (95% CI, 0.46 to 0.56), P &lt
0.001). The association between paracetamol and decreased mortality and/or time to death was broadly consistent across surgical and medical patients. It remained present after adjusting for paracetamol administration as a time-dependent variable. However, when such time-dependent analysis was performed, the association of paracetamol with outcome lost statistical significance in the presence of fever and suspected infection and in patients in the lower tertiles of Acute Physiology and Chronic Health Evaluation II scores. Conclusions: Paracetamol administration is common in the ICU and appears to be independently associated with reduced in-hospital mortality and time to death after adjustment for multiple potential confounders and propensity score. This association, however, was modified by the presence of fever, suspected infection and lesser illness severity and may represent the effect of indication bias.

DOI： 10.1186/s13054-015-0865-1

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BIOMED CENTRAL LTD  

Background: Cardiac arrest causes ischaemic brain injury. Arterial carbon dioxide tension (PaCO2) is a major determinant of cerebral blood flow. Thus, mild hypercapnia in the 24 h following cardiac arrest may increase cerebral blood flow and attenuate such injury. We describe the Carbon Control and Cardiac Arrest (CCC) trial.
Methods/Design: The CCC trial is a pilot multicentre feasibility, safety and biological efficacy randomized controlled trial recruiting adult cardiac arrest patients admitted to the intensive care unit after return of spontaneous circulation. At admission, using concealed allocation, participants are randomized to 24 h of either normocapnia (PaCO2 35 to 45 mmHg) or mild hypercapnia (PaCO2 50 to 55 mmHg). Key feasibility outcomes are recruitment rate and protocol compliance rate. The primary biological efficacy and biological safety measures are the between-groups difference in serum neuron-specific enolase and S100b protein levels at 24 h, 48 h and 72 h. Secondary outcome measure include adverse events, in-hospital mortality, and neurological assessment at 6 months.
Discussion: The trial commenced in December 2012 and, when completed, will provide clinical evidence as to whether targeting mild hypercapnia for 24 h following intensive care unit admission for cardiac arrest patients is feasible and safe and whether it results in decreased concentrations of neurological injury biomarkers compared with normocapnia. Trial results will also be used to determine whether a phase IIb study powered for survival at 90 days is feasible and justified.

DOI： 10.1186/s13063-015-0676-3

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：W B SAUNDERS CO-ELSEVIER INC  

Purpose: Resuscitated cardiac arrest (CA) patients typically receive therapeutic hypothermia, but arterial blood gases (ABGs) are often assessed after adjustment to 37 degrees C (alpha-stat) instead of actual body temperature (pH-stat). We sought to compare alpha-stat and pH-stat assessment of Pao(2) and Paco(2) in such patients.
Materials and methods: Using ABG data obtained during the first 24 hours of intensive care unit admission, we determined the impact of measured alpha vs calculated pH-stat on Pao(2) and Paco(2) on patient classification and outcomes for CA patients.
Results: We assessed 1013 ABGs from 120 CA patients with a median age of patients 66 years (interquartile range, 50-76). Median alpha-stat Pao(2) changed from 122 (95-156) to 107 (82-143) mm Hg with pH-stat and median Paco(2) from 39 (34-46) to 35 (30-41) mm Hg (both P &lt; .001). Using the categories of hyperoxemia, normoxemia, and hypoxemia, pH-stat estimation of Pao(2) reclassified approximately 20% of patients. Using the categories of hypercapnia, normocapnia, and hypocapnia, pH-stat estimation of Paco(2) reclassified approximately 40% of patients. The mortality of patients in different Pao(2) and Paco(2) categories was similar for pH-stat and alpha-stat.
Conclusions: Using the pH-stat method, fewer resuscitated CA patients admitted to intensive care unit were classified as hyperoxemic or hypercapnic compared with alpha-stat. These findings suggest an impact of ABG assessment methodology on Pao(2), Paco(2), and patient classification but not on associated outcomes. (C) 2014 Elsevier Inc. All rights reserved.

DOI： 10.1016/j.jcrc.2014.09.022

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：W B SAUNDERS CO-ELSEVIER INC  

Purpose: The aim of this study is to study the feasibility, safety, and physiological effects of pulse pressure variation (PPV)-guided fluid therapy in patients after cardiac surgery.
Materials and methods: We conducted a pilot prospective before-and-after study during mandatory ventilation after cardiac surgery in a tertiary intensive care unit. We introduced a protocol to deliver a fluid bolus for a PPV &gt;= 13% for at least &gt;10 minutes during the intervention period.
Results: We studied 45 control patients and 53 intervention patients. During the intervention period, clinicians administered a fluid bolus on 79% of the defined PPV trigger episodes. Median total fluid intake was similar between 2 groups during mandatory ventilation (1297 mL[interquartile range 549-1968] vs 1481 mL [807-2563]; P =. 17) and the first 24 hours (3046 mL [interquartile range 2317-3982] vs 3017 mL [2192-4028]; P = .73). After adjusting for several baseline factors, PPV-guided fluid management significantly increased fluid intake during mandatory ventilation (P = .004) but not during the first 24 hours (P = .47). Pulse pressure variation-guided fluid therapy, however, did not significantly affect hemodynamic, renal, and metabolic variables. No serious adverse events were noted.
Conclusions: Pulse pressure variation-guided fluid management was feasible and safe during mandatory ventilation after cardiac surgery. However, its advantages may be clinically small. (C) 2014 Elsevier Inc. All rights reserved.

DOI： 10.1016/j.jcrc.2014.07.032

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER SCIENCE INC  

Background: In the ICU, SpO(2) &gt;= 96% are regularly targeted implying that more oxygen may be given than desirable. To reduce exposure to hyperoxia a conservative oxygen therapy protocol (targeted SpO(2) 90-92% using lowest FiO(2)) for mechanically ventilated patients was introduced in a single tertiary ICU in September 2012.
Objectives: To describe intensive care clinicians' opinion of conservative oxygen therapy for mechanically ventilated adult patients.
Methods: A structured multi-choice questionnaire of intensive care clinicians was conducted between February and March 2013.
Results: Responses were received from 90 staff members: 81 intensive care nurses and 9 medical doctors. A majority of respondents (60.7%) considered oxygen related lung injury as 'a major concern'. Most respondents (81/89; 91.1%) felt conservative oxygen therapy was easy to perform and few respondents (6/88; 8%) considered performing conservative oxygen therapy to be stressful. Most respondents (58%) reported not performing more arterial blood gases to monitor PaO2 during conservative oxygen therapy and 90% (81/90) of respondents indicated a desire to continue conservative oxygen therapy. Free text comments indicated adoption of this protocol was a paradigm shift yet more education and research to elucidate the benefits/harm of lower oxygen saturation targeting is needed.
Conclusions: Intensive care clinicians readily accepted the introduction of a conservative oxygen therapy protocol into their practice. Most respondents found conservative oxygen therapy easy and not stressful to perform. Further evaluation the administration of oxygen therapy, its management by intensive care clinicians and possible impact on outcome for mechanically ventilated patients appears well accepted by clinical staff. (C) 2013 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Critical Care Nurses Ltd.

DOI： 10.1016/j.aucc.2013.11.004

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Objectives: To assess the feasibility and safety of a conservative approach to oxygen therapy in mechanically ventilated ICU patients.
Design: Pilot prospective before-and-after study.
Setting: A 22-bed multidisciplinary ICU of a tertiary care hospital in Australia.
Patients: A total of 105 adult (18 years old or older) patients required mechanical ventilation for more than 48 hours: 51 patients during the conventional before period and 54 after a change to conservative oxygen therapy.
Interventions: Implementation of a conservative approach to oxygen therapy (target Spo(2) of 90-92%).
Measurements and Main Results: We collected 3,169 datasets on 799 mechanical ventilation days. During conservative oxygen therapy the median time-weighted average Spo(2) on mechanical ventilation was 95.5% (interquartile range, 94.0-97.3) versus 98.4% (97.3-99.1) (p &lt; 0.001) during conventional therapy. The median Pao(2) was 83 torr (71-94) versus 107 torr (94-131) (p &lt; 0.001) with a change to a median Fio(2) of 0.27 (0.24-0.30) versus 0.40 (0.35-0.44) (p &lt; 0.001). Conservative oxygen therapy decreased the median total amount of oxygen delivered during mechanical ventilation by about two thirds (15,580 L [8,263-29,351 L] vs 5,122 L [1,837-10,499 L]; p &lt; 0.001). The evolution of the Pao(2)/Fio(2) ratio was similar during the two periods, and there were no difference in any other biochemical or clinical outcomes.
Conclusions: Conservative oxygen therapy in mechanically ventilated ICU patients was feasible and free of adverse biochemical, physiological, or clinical outcomes while allowing a marked decrease in excess oxygen exposure. Our study supports the safety and feasibility of future pilot randomized controlled trials of conventional compared with conservative oxygen therapy.

DOI： 10.1097/CCM.0000000000000219

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IMPORTANCE Severe sepsis and septic shock are major causes of mortality in intensive care unit (ICU) patients. It is unknown whether progress has been made in decreasing their mortality rate.
OBJECTIVE To describe changes in mortality for severe sepsis with and without shock in ICU patients.
DESIGN, SETTING, AND PARTICIPANTS Retrospective, observational study from 2000 to 2012 including 101 064 patients with severe sepsis from 171 ICUs with various patient case mix in Australia and New Zealand.
MAIN OUTCOMES AND MEASURES Hospital outcome (mortality and discharge to home, to other hospital, or to rehabilitation).
RESULTS Absolute mortality in severe sepsis decreased from 35.0% (95% CI, 33.2%-36.8%; 949/2708) to 18.4% (95% CI, 17.8%-19.0%; 2300/12 512; P&lt;.001), representing an overall decrease of 16.7% (95% CI, 14.8%-18.6%), an annual rate of absolute decrease of 1.3%, and a relative risk reduction of 47.5% (95% CI, 44.1%-50.8%). After adjusted analysis, mortality decreased throughout the study period with an odds ratio (OR) of 0.49 (95% CI, 0.46-0.52) in 2012, using the year 2000 as the reference (P&lt;.001). The annual decline in mortality did not differ significantly between patients with severe sepsis and those with all other diagnoses (OR, 0.94 [95% CI, 0.94-0.95] vs 0.94 [95% CI, 0.94-0.94]; P = .37). The annual increase in rates of discharge to home was significantly greater in patients with severe sepsis compared with all other diagnoses (OR, 1.03 [95% CI, 1.02-1.03] vs 1.01 [95% CI, 1.01-1.01]; P&lt;.001). Conversely, the annual increase in the rate of patients discharged to rehabilitation facilities was significantly less in severe sepsis compared with all other diagnoses (OR, 1.08 [95% CI, 1.07-1.09] vs 1.09 [95% CI, 1.09-1.10]; P&lt;.001). In the absence of comorbidities and older age, mortality was less than 5%.
CONCLUSIONS AND RELEVANCE In critically ill patients in Australia and New Zealand with severe sepsis with and without shock, there was a decrease in mortality from 2000 to 2012. These findings were accompanied by changes in the patterns of discharge to home, rehabilitation, and other hospitals.

DOI： 10.1001/jama.2014.2637

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Language：English   Publisher：W B SAUNDERS CO-ELSEVIER INC  

DOI： 10.1016/j.jcrc.2013.10.002

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：AUSTRALASIAN MED PUBL CO LTD  

Background: Near-infrared spectroscopy of the thenar eminence (NIRSth) can be used at the bedside to assess tissue oxygenation (Sto(2)), the reperfusion response to ischaemia and the tissue haemoglobin index (THI). Its ability to estimate forearm blood flow (FBF) has not previously been assessed.
Objectives: We aimed to test whether short-lived venous occlusion-induced changes in NIRSth-derived THI (Delta THI/minute) correlate with strain gauge plethysmography (SGP) measurements.
Methods: We measured FBF in nine volunteers with SGP by venous occlusion, while estimating Delta THI. Measurements were obtained in two forearm positions (elevated and horizontal) at baseline and during induced hyperaemia.
Results: We performed 246 paired measurements at rest and after occlusion-induced hyperaemia. At rest, mean SGP-estimated FBF was 3.5-3.6 mL/dL/minute at baseline, compared with 12.9-13.6 mL/dL/minute during hyperaemia. At rest, Delta THI was 6.1-8.2/minute, compared with 29.7-32.5/minute during hyperaemia. Delta THI was a significant predictor of SGP FBF (P&lt;0.01), with stronger correlation during hyperaemia (P&lt;0.01). An equation was developed to convert Delta THI/minute into FBF at mL/dL/minute (FBF=0.362 x Delta THI/minute + 0.864).
Conclusions: NIRSth can be used to estimate FBF. Given its portability and its ability to also measure Sto(2) and vascular reactivity, NIRSth can assist in providing a comprehensive bedside assessment of the forearm circulation in critically ill patients.

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Purpose: Oxygen (O-2) is the most common therapy in mechanically ventilated patients, but targets and dose are poorly understood. We aimed to describe current O-2 administration and titration in such patients in an academic intensive care unit.
Materials and Methods: In consecutive ventilated (&gt; 48 hours) patients we prospectively obtained fraction of inspired O-2 (FIO2), pulse oximetry O-2 saturation (SpO(2)) and arterial O-2 tension (PaO2) every 6 hours. We calculated the amount of excess O-2 delivery and the intensivists' response to hyperoxemia (SpO(2) &gt; 98%).
Results: During 358 mechanical ventilation days in 51 critically ill patients, median calculated excess O-2 delivery was 3472 L per patient. Patients spent most of their time with their SpO(2) &gt; 98% (59% [29-83]) and PaO2 between 80 and 120 mm Hg (59% [38-72]). In addition, 50% of all observations showed hyperoxemia and 4% severe hyperoxemia (PaO2 &gt; 202.5 mm Hg). Moreover, 71% of the calculated total excess 263,841 L of O-2 was delivered when the FIO2 was 0.3 to 0.5. When hyperoxemia occurred with an FIO2 between 0.3 and 0.4, for 88% of episodes, no FIO2 adjustments were made.
Conclusions: Excess O-2 delivery and liberal O-2 therapy were common in mechanically ventilated patients. Current O-2 therapy practice may be suboptimal and further investigations are warranted. (C) 2013 Elsevier Inc. All rights reserved.

DOI： 10.1016/j.jcrc.2013.03.010

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Purpose: The aim of this study was to assess the association of phosphate concentration with key clinical outcomes in a heterogeneous cohort of critically ill patients. Materials and Methods: This was a retrospective observational study at a general intensive care unit (ICU) of an Australian university teaching hospital enrolling 2730 adult critically ill patients. Results: We studied 10 504 phosphate measurements with a mean value of 1.17 mmol/L (measurements every 28.8 hours on average). Hyperphosphatemia (inorganic phosphate [iP] concentration &gt
1.4 mmol/L) occurred in 45% and hypophosphatemia (iP ≤ 0.6 mmol/L) in 20%. Among patients without any episodes of hyperphosphatemia, patients with at least 1 episode of hypophosphatemia had a higher ICU mortality than those without hypophosphatemia (P = .004). In addition, ICU nonsurvivors had lower minimum phosphate concentrations than did survivors (P = .009). Similar results were seen for hospital mortality. However, on multivariable logistic regression analysis, hypophosphatemia was not independently associated with ICU mortality (adjusted odds ratio, 0.86 [95% confidence interval, 0.66-1.10]
P = .24) and hospital mortality (odds ratio, 0.89 [0.73-1.07]
P = .21). Even when different cutoff points were used for hypophosphatemia (iP ≤ 0.5, 0.4, 0.3, or 0.2 mmol/L), hypophosphatemia was not an independent risk factor for ICU and hospital morality. In addition, timing of onset and duration of hypophosphatemia were not independent risk factor for ICU and hospital mortality. Conclusions: Hypophosphatemia behaves like a general marker of illness severity and not as an independent predictor of ICU or in-hospital mortality in critically ill patients. © 2013 Elsevier Inc.

DOI： 10.1016/j.jcrc.2012.10.011

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Liver transplantation is a major life-saving procedure and donation after cardiac death (DCD) has increased the pool of potential liver donors.
However, livers procured after DCD are at increased risk of primary graft dysfunction and biliary tract ischaemia. Normothermic extracorporeal liver perfusion (NELP) may increase the ability to protect, evaluate and, in future, transplant DCD livers.
We conducted a proof-of-concept experiment using a human liver procured by DCD (deemed not suitable for liver donation) to assess the short-term (3 hours) feasibility,, histological effects and functional efficacy of NELP.
We used an extracorporeal membrane oxygenation circuit with separate hepatic artery and portal vein perfusion to achieve physiological perfusion pressures, and coupled this with parenteral nutrition and an insulin infusion. We achieved NELP with evidence of liver function (bile production, paracetamol removal and control of ammonia, bilirubin and lactate levels) for 3 hours. There was essentially normal liver and biliary tract histology after 8 hours of perfusion.
Our experiment justifies further investigation of the feasibility and efficacy of human DCD liver preservation by NELP.

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Liver transplantation is a major life-saving procedure, and donation after cardiac death (DCD) has increased the pool of potential liver donors.
However, DCD livers are at increased risk of primary graft dysfunction and biliary tract ischaemia. Normothermic extracorporeal liver perfusion (NELP) may increase the ability to protect, evaluate and, in future, transplant DCD livers.
We conducted proof-of-concept experiments using a DCD model in the pig to assess the short-term (4 hours) feasibility and functional efficacy of NELP. Using extracorporeal membrane oxygenation, parenteral nutrition, separate hepatic artery and portal vein perfusion, and physiological perfusion pressures, we achieved NELP and evidence of function (bile production, paracetamol removal, maintenance of normal ammonia and lactate levels) for 4 hours in pig livers subjected to 15 and 30 minutes of cardiac arrest before explantation.
Our experiments justify further investigations of the feasibility and efficacy of human DCD liver preservation by ex-vivo perfusion.

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Purpose The benefit of tranexamic acid (TXA) in pediatric cardiac surgery on postoperative bleeding has varied among studies. It is also unclear whether the effects of TXA differ between cyanotic patients and acyanotic patients. The aim of this study was to test the benefit of TXA in pediatric cardiac surgery in a well-balanced study population of cyanotic and acyanotic patients.
Methods A total of 160 pediatric patients undergoing cardiac surgery with cardiopulmonary bypass (81 cyanotic, 79 acyanotic) were included in this single-blinded, randomized trial at a tertiary care university-affiliated teaching hospital. Eighty-one children (41 cyanotic, 40 acyanotic) were randomly assigned to a TXA group, in which they received 50 mg/kg of TXA as a bolus followed by 15 mg/kg/h infusion and another 50 mg/kg into the bypass circuit. The other 79 patients were randomly assigned to a placebo group. The primary end point was the amount of 24-h blood loss.
Results The amount of 24-h blood loss was significantly less in the TXA group than in the placebo group [mean (95% confidence interval): 18.6 (15.8-21.4) vs. 23.5 (19.4-27.5) ml/kg, respectively; mean difference -4.9 (-9.7 to -0.01) ml/kg; p = 0.049]. This effect of TXA was already significant at 6 h [9.5 (7.5-11.5) vs. 13.2 (10.6-15.9) ml/kg, respectively; mean difference -3.47 (-7.0 to -0.4) ml/kg; p = 0.027]. However, there was no significant difference in the amount of blood transfusion between the groups. There was also no statistical difference in the effect of TXA in each cyanotic and acyanotic subgroup.
Conclusion TXA can reduce blood loss in pediatric cardiac surgery but not the transfusion requirement (http://ClinicalTrials.gov number NCT00994994).

DOI： 10.1007/s00540-011-1235-z

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A male child, aged 1 year, with pulmonary atresia, ventricular septal defect and major aorto-pulmonary collateral arteries (PA, VSD, MAPCA) underwent corrective surgery including MAPCA ligation uneventfully. A few hours after admission to the ICU, severe heart failure, refractory to aggressive cardiac support including epinephrine infusion, became worse. Emergent cardiac catheterization on postoperative day 5 demonstrated the residual MAPCA and its occlusion by coil embolization dramatically resolved heart failure, indicating that the primary cause of this hemodynamic instability was likely excessive left-to-right shunt due to MAPCA. Residual LR shunt should be kept in mind to be a rare but significant cause of postoperative serious heart failure.

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Amiodarone is widely used in Europe and the United States for refractory ventricular fibrillation (VF) in various situations, such as VF after myocardial infarction or out-of-hospital cardiac arrest. We report a case of successful treatment with amiodarone of refractory VF immediately after releasing aortic cross-clamp in cardiac surgery. A 66-year-old man suffering from severe aortic stenosis underwent aortic valve replacement (AVR). General anesthesia was induced with propofol and remifentanil, and subsequently AVR was performed under cardiopulmonary bypass. Just after releasing aortic cross-clamp, VF occurred, and it continued despite multiple trials of cardioversion with direct current (DC) shocks of 20 J or 30 J. Furthermore, some DC shocks of 30 J or 50 J after administering lidocaine 60 mg and 0.5 mol·l-1 magnesium sulfate 20 ml were also ineffective. Then, nifekalant 20 mg was administered and DC shocks of 50 J were repeated intermittently, but VF still persisted. Eventually, VF disappeared after a final DC shock of 50 J with intravenous amiodarone 125 mg. Overall duration of VF was 60 minutes. The patient's trachea was extubated three days after the surgery without any complications. Intravenous amiodarone may be one of the most useful remedies for some types of arrhythmias including persistent VF.

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Hypoplastic left heart syndrome (HLHS) with intact atrial septum (IAS) is an extreme type of single ventricle physiology among congenital heart diseases, in which a baby cannot supply oxygenated blood into systemic circulation without alternative pathway. We report the case of the neonate undergoing open balloon atrial septostomy (BAS) and bilateral pulmonary artery banding (PAB) soon after scheduled caesarean sections (C/S). A 35-year-old female was pregnant and fetal echocardiography at 32 weeks revealed one of the twins as HLHS/IAS. Severe hypoxia soon after birth was suspected. Thus, scheduled C/S followed by open BAS was planned. At 36 weeks of gestation, the mother was anesthetized with spinal bupivacaine and the female baby with HLHS/IAS was delivered. After diagnosed definitely by pediatric cardiologists, her trachea was intubated by anesthegiologists and umbilical catheters were placed by neonatologists. Then the baby was transferred to neighboring operating theater for BAS 68 minutes after the birth, while her SpO2 was maintained around 75-85% through serial procedures. Open BAS and PAB were performed under general anesthesia without any hemodynamic instability or severe hypoxia. Cooperation among anesthegiologists, neonatologists, pediatric cardiologists, and cardiac surgeons is mandatory in order to successfully complete such a rushed procedure.

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SPANDIDOS PUBL LTD  

The progression and interrelationship of mediators that are released, activated or suppressed after major surgery appear to play an important role in responses to surgical stress. Heat shock protein 70 (HSP70) is stress-induced and acts like a cytokine to modulate pro-inflammatory mediators, such as tumor necrosis factor-alpha (TNF-alpha) and inducible nitric oxide synthase (iNOS), by stimulating toll-like receptor 4 (TLR4) signaling. We hypothesized that this effect would occur after major surgery, such as esophagectomy. We therefore measured the expression of HSP70, TLR4, TNF-alpha and iNOS mRNA in peripheral blood mononuclear cells (PBMCs) from 11 patients who underwent esophagectomy with thoracoabdominal procedures at postoperative day (POD) 1 and POD3 using real-time polymerase chain reaction, and compared the results to expression levels in 6 healthy adult volunteers (controls). We also measured plasma cortisol as a well-known stress hormone. The expression of HSP70 mRNA in PBMCs was 2.1-fold higher on POD1 compared to the controls (P=0.041) and was positively correlated with TLR4 mRNA (r(2)=0.45, P=0.0007). The expression of TNF-alpha mRNA tended to be lower on POD1 (P=0.055) and was significantly decreased on POD3 (P=0.016), and iNOS mRNA were significantly lower on POD1 (P=0.0015) and POD3 (P=0.0003) compared to the controls. Moreover, there was a positive correlation between the expression of TLR4 mRNA and plasma cortisol levels (r(2)=0.24, P=0.021). The expression of HSP70 mRNA in PBMCs in the early postoperative period was significantly higher and positively correlated with TLR4 mRNA. This suggests that HSP70-TLR4 signaling has an important role in postoperative inflammatory responses. However, the expression of pro-inflammatory mediators, including TNF-alpha and iNOS mRNA, was significantly decreased postoperatively. This may be caused by the anti-inflammatory mechanism of cortisol. Our findings indicate that responses to surgical stress reflect simultaneous pro-inflammatory and anti-inflammatory responses, and are complex.

DOI： 10.3892/mmr.2010.335

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Language：Japanese   Publisher：(NPO)日本小児循環器学会  

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We aimed to clarify the acid-base abnormalities of patients with acute kidney injury (AKI) requiring peritoneal dialysis (PD) in pediatric cardiac care units.
A retrospective observational study was conducted in a pediatric cardiac care unit in a tertiary care university hospital. The subjects were 40 patients with AKI requiring PD between 2003 and 2005, and controls matched by type of surgery and body weight. Acid-base variables, including blood gas data and electrolytes, were assessed. The Stewart-Figge variables, including strong ion difference apparent (SIDa), strong ion difference effective (SIDe), and strong ion gap (SIG), were calculated.
Blood gas analyses showed that the PD group was more acidemic, with a lower mean bicarbonate and a lower mean base excess, typical features of metabolic acidosis. The strong ion analyses revealed that the PD group had lower mean sodium and albumin concentrations. Based on the Stewart-Figge methodology, SIDa was smaller in the PD group than in the control group, but SIG was similar in the two groups. Receiver-operating characteristic curve analyses showed that serum albumin was the only prognostic factor associated with PCCU mortality, even after adjustment for PD treatment.
Patients with AKI requiring PD in a pediatric cardiac care unit had significant metabolic acidosis compared to controls matched by the type of surgery and body weight. Hyponatremia and hypoalbuminemia were characteristics of these patients. The calculated SIDa was smaller in the PD than in the control group. Only the serum albumin had a significant prognostic value.

DOI： 10.1007/s00540-009-0747-2

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Language：Japanese   Publisher：(一社)日本心臓血管麻酔学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SCHATTAUER GMBH-VERLAG MEDIZIN NATURWISSENSCHAFTEN  

Validation of a scoring algorithm for non-overt disseminated intravascular coagulation (DIC) proposed by the International Society on Thrombosis and Haemostasis (ISTH) is still incomplete. It was the objective of this study to assess the impact of including AT to non-overt DIC scoring on the predictability for intensive care unit (ICU) death and the later development of overt-DIC defined by the Japanese Ministry of Health and Welfare (JMHW) or the ISTH. We performed a retrospective observational study conducted in 364 patients in critical care. Coagulation parameters obtained daily for DIC screening were utilised for scoring. There were 194 and 196 patients scored as positive non-overt DIC with and without AT, respectively; diagnostic agreement between the two was 78%. As compared with patients without non-overt DIC, these non-overt DIC patients had significantly higher mortality. In 37 ICU non-survivors, positive non-overt DIC scoring with AT preceded ICU death by a median of 6.8 days, which was significantly earlier as compared with a median of 5.4 days for non-overt DIC without AT (p=0.022). In patients who developed overt-DIC after admission, the time period from positive non-overt DIC to positive overt-DIC was significantly longer when AT was utilised (overt-DIC ISTH; 1.3 days vs. 0.1 days, p=0.004, overt-DIC JMHW; 2.5 days vs. 2.0 days, p=0.04, with AT vs. without AT, respectively). Non-overt DIC scoring predicted a high risk of death in critically ill patients. When information on AT levels was included, non-overt DIC scoring was found to predict development of overt-DIC significantly earlier than non-overt DIC scoring without AT.

DOI： 10.1160/TH08-07-0448

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Insulinomas are rare tumors, the incidence of which is 1-2 per million. Patients with insulinomas present with symptoms of hypoglycemia secondary to insulin hypersecretion. Surgical resection is a treatment of choice and offers the only chance of cure. The important points in anesthesia are the precaution against hypoglycemia until tumor resection and the control of rebound hyperglycemia soon after tumor resection. We report the anesthetic management of a 5-year-old patient with insulinoma. Soon after the induction of anesthesia, the continuous glucose monitoring was commenced. Until the tumor resection, 10% glucose infusion was required to avoid hypoglycemia. Then, insulin infusion was continued to maintain blood glucose level around 150 mg·dl-1. All glucose management was guided with continuous glucose monitoring. This is a first case report to show the feasibility and usefulness of continuous glucose monitoring in management of pediatric insulinoma patients. As the blood glucose was dramatically altered during perioperative period, frequent blood glucose measurements or continuous glucose monitoring is mandatory during perioperative period of insulinoma resection.

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese Book type：Textbook, survey, introduction

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Language：English   Publishing type：Rapid communication, short report, research note, etc. (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

DOI： 10.1161/CIRCULATIONAHA.113.004554

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

術後の発作性心房細動の発生は、ICUや病院滞在日数、医療費の増加につながることが報告されており、その管理は重要である。我々は、食道癌術後に難治性の発作性心房細動を合併し、短時間作用型β1選択的遮断薬である塩酸ランジオロールを使用した7例を経験した。症例は51〜87歳で、いずれも男性であった。複数の抗不整脈薬が無効であり、塩酸ランジオロール投与を開始した。初期の急速投与は行わず、4.3〜33.5μg/kg/minと低用量の範囲で開始し、投与前と投与1時間後の心拍数は平均153[140、167][95%信頼区間]/minから101[88、116]/min(P<0.0001)と有意な低下を認めた。平均血圧は88[78、94]mmHgから82[74、89]mmHg(P=0.37)と有意な変化を認めず、重症な低血圧に陥る症例もなかった。6例では投与開始24時間以内に洞調律に回復した。複数の抗不整脈薬に抵抗性の食道癌術後発作性心房細動に対する低用量の塩酸ランジオロール投与は、大きな血圧の低下なく心拍数の安定をもたらした。(著者抄録)

DOI： 10.3918/jsicm.18.215

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2011&ichushi_jid=J02874&link_issn=&doc_id=20110422460012&doc_link_id=20110422460001%2C20111017450026&url=http%3A%2F%2Fsearch.jamas.or.jp%2Flink%2Fbc%2F20110422460001%2C20111017450026&type=jamaslink&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F99999_1.gif

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2006年12月〜2007年6月に、ICU入室後に筋弛緩薬を持続投与された先天性心疾患40例(6.3〜15.8ヵ月・平均11ヵ月)を対象に、挿管時間への影響因子について検討した。40例のうち37例(92.5%)は心臓手術後患者で、施行術式はRACHS-1カテゴリーで2.8〜3.6(平均3.2)、人工心肺時間92〜140分(平均116分)、大動脈遮断時間49〜82分(平均65分)、人工心肺中の冷却温度は24.8〜28.4℃(平均26.6℃)であった。ICU入室中に投与したベクロニウムの総投与量は3.3〜11.7mg・kg-1(平均7.5mg・kg-1)、持続投与中止から抜管までの時間は48.4〜153.9時間(平均101.1時間)と4日間を要していた。そのうち約80%の症例は100時間以内に抜管可能であった。5例は抜管まで200時間以上と長時間を要した。挿管時間と各因子の比例ハザードモデルによる単変量解析の結果、ベクロニウム総投与量と人工心肺冷却温度が有意に独立した危険因子であった。

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2010&ichushi_jid=J02874&link_issn=&doc_id=20100730590017&doc_link_id=10.3918%2Fjsicm.17.353&url=https%3A%2F%2Fdoi.org%2F10.3918%2Fjsicm.17.353&type=J-STAGE&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00007_3.gif

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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Language：Japanese   Publisher：日本臨床麻酔学会  

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Language：Japanese   Publisher：(一社)日本心臓血管麻酔学会  

先天性心疾患患者への腸回転異常修復術における麻酔を経験した。症例は2歳9ヵ月男児で、生後すぐに心雑音を指摘された。生後10日目に心エコー検査で無脾症、単心房、共通房室弁孔、両大血管右室起始、総肺静脈還流異常(TAPVC)、superior-inferior ventricleと診断され、TAPVC修復術、肺動脈絞扼術が施行された。生後7ヵ月で両方向性グレン手術とvertical vein ligationが施行された。今回、両大静脈肺動脈吻合法予定で入院したが、腸回転異常が認められ、入院後17日目に待機的に腸回転異常修復術を施行した。本症例の麻酔経過を述べ、このような患児の麻酔を安全に行うためには原疾患の血行動態を把握する必要があることを指摘した。非心臓手術の対象となる疾患の理解も必要である。

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Language：Japanese   Publisher：(NPO)日本小児循環器学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Web of Science

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Language：Japanese   Publisher：(株)総合医学社  

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Language：Japanese   Publisher：日本小児麻酔学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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J-GLOBAL

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Language：Japanese   Publisher：(一社)日本心臓血管麻酔学会  

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Language：Japanese   Publisher：(一社)日本心臓血管麻酔学会  

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Presentation type：Symposium, workshop panel (public)  

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Language：English   Presentation type：Oral presentation (general)  

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Language：Japanese   Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Event date： 2019.5.30 - 2019.6.1

Language：Japanese   Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Language：Japanese   Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Symposium, workshop panel (nominated)  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Symposium, workshop panel (nominated)  

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Presentation type：Symposium, workshop panel (nominated)  

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Presentation type：Symposium, workshop panel (nominated)  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Symposium, workshop panel (nominated)  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Symposium, workshop panel (nominated)  

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Presentation type：Symposium, workshop panel (nominated)  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Symposium, workshop panel (nominated)  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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Presentation type：Symposium, workshop panel (nominated)  

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Presentation type：Symposium, workshop panel (nominated)  

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Presentation type：Symposium, workshop panel (public)  

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Presentation type：Public lecture, seminar, tutorial, course, or other speech  

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